Pain scales don't weigh every risk

From the July 24, 2002 issue

PROBLEM: Spurred by the 2001 Joint Commission pain management
standards, many health systems have revamped the way they manage
pain and, rightfully so, made patient comfort a high priority.
But in our noble efforts to alleviate pain, has safety been
compromised? Although literature supports that patients are
under-treated for pain, error reports in the past year show
a glimpse of perhaps overaggressive attempts to ensure that
patients experience no discomfort. Most recently, we heard about
a 24-year-old woman who died from fentanyl toxicity less than
24 hours after giving birth by Cesarean section. She had been
given several doses of fentanyl IV before and after the birth.
That evening, she fed and cared for her daughter. In the early
morning, she again complained of pain and the dose of fentanyl
IV was increased. She asked for a blanket 30 minutes later,
but was found in cardiac arrest within half an hour . While
this is an extreme example of what can go wrong with pain management,
clinicians at several hospitals have reported concern to us
about an alarming increase in oversedation of patients who are
receiving pain medications.

Problems with pain management can be linked to insufficient
patient monitoring. Too often pain scores are elicited from
patients, but not closely associated with each dose of analgesic.
Respiratory rates are counted, but depth and quality may not
be considered. Treatment and monitoring may not be altered
for patients with a history of sleep apnea. The cumulative
effects of narcotics given at the end of a surgical procedure
and then again in PACU may not be considered, especially after
the patient is transferred to a nursing unit.

An equally serious problem is that many patients are prescribed
a virtual cornucopia of pain management options in multiple
routes and dosages linked only to the patient's assessment
of pain. For example, a patient may be prescribed acetaminophen
650 mg PO q4h for pain scale 1-3; codeine 30 mg PO q4h for
pain scale 4-6, morphine 2 mg IV q3h for pain scale 7-8; and
morphine 4 mg IV q4h for pain scale 9-10. Thus, if a patient
with a low threshold for pain reports discomfort on the high
end of the scale, the nurse may administer morphine at the
higher dose without careful consideration of the patient's
clinical status and cumulative effects of drug therapy. Likewise,
if a patient with a high threshold for pain rates his discomfort
on the low end of the pain scale, the nurse may simply administer
the acetaminophen. While clinicians should not substitute
their judgment for the patient's self-report of pain, perhaps
we have left too little room to integrate the patient's assessment
of pain with the clinician's objective evaluation of the patient's
response to the medication and, most importantly, safety considerations.

SAFE PRACTICE RECOMMENDATION: First, organizations
need to know how well they are managing pain. In addition
to patient satisfaction evaluations, hospitals should seek
out episodes of oversedation by monitoring adverse drug reaction
reports, investigating all use of narcotic reversal agents,
and reviewing patient records to determine the effectiveness
of pain management therapy. Hold focus groups with clinicians,
especially nurses, to discuss the many challenges with managing
pain and carefully monitoring patients. Clearly determine
the variables that should be considered when selecting the
most effective and safe pain management therapy (patient's
pain assessment, cultural and ethnic beliefs, clinical observations,
patient monitoring parameters). Reduce the variety of analgesics
prescribed to patients and evaluate the medications and methods
of delivery that are being used frequently. For example, morphine
4 mg IV is commonly prescribed, but fluctuating peak and trough
levels make pain management difficult. Hydromorphone (DILAUDID)
1-4 mg IV is another common order, but it is equivalent to
8-32 mg of morphine.
PCA is prescribed often without thoughtful one or four hour
limits. Promethazine or hydroxyzine may be added to the regimen,
which increases sedation but not analgesic efficacy. NSAIDs
and nonpharmacological approaches may be underutilized.

It's also important to eliminate orders with dosage ranges
and link specific dosages to the patient's overall response
to therapy and clinical status, not to the patient's self
assessment of pain alone. Finally, pharmacists should play
a more active role in pain management. In our last issue,
we mentioned that pain management was the least frequent area
for pharmacy interventions. Yet, it is ripe for expanded clinical
pharmacy services because of the dire consequences of errors
when using powerful narcotics. Even if a physician-driven
pain management service is currently available, consider having
both a pharmacist and a nurse join the team to broaden the
coverage to more routine types of pain management and to enhance
patient assessment and monitoring.

Managing pain has never been more complicated. There's a wide
variety of different analgesics available on the market; dosage
forms that range from lollipops to patches; an assortment
of delivery vehicles from implantable devices to patient controlled
analgesia (PCA); and varying routes of administration. Now
more than ever, it's imperative for healthcare organizations
to revisit this issue to ensure a safe, effective, and realistic
approach to managing pain.